SAKK C-SGA_Table2_19Aug13
Table 2: Detailed contents of the SAKK Cancer-Specific Geriatric Assessment (C-SGA)
MEDICAL RECORD ABSTRACT (MRA)
Charlson Comorbidty Index (CCI)
__________ un-age-adjusted
___________ age-adjusted
Note: Calculate using reference 28
Body Mass Index (BMI) __________ = weight(kg) / height²(m²)
__________ weight in kg
__________ height in cm
PATIENT INTERVIEW
Vulnerable Elders Survey (VES-13)
1. In general, compared to other people your age, would
you say that your health is:
Poor
Fair
Good
Very Good
Excellent
1
1
0
0
0
2. How much difficulty, on average, do you have with the following physical activities:
No difficulty
a. Stooping, crouching or kneeling?
b. Lifting, or carrying objects as heavy
as 10 pounds?
c. Reaching or extending arms above
shoulder level?
d. Writing, or handling and grasping
small objects?
e. Walking a quarter of a mile?
f. Heavy housework such as scrubbing
floors or washing windows?
0
0
A little
difficulty
0
0
Some
difficulty*
1
1
A lot of
difficulty*
1
1
Unable to
do*
1
1
0
0
1
1
1
0
0
1
1
1
0
0
0
0
1
1
1
1
1
1
3. Because of your health or a physical condition, do you have any difficulty:
a. Shopping for personal items (like Yes
→ Do you get help with shopping?
toilet items or medicine)?
No
Don’t do
→ Is that because of your health?
b. Managing money (like keeping
Yes
→ Do you get help with managing
track of expenses or paying
money?
bills)?
No
Don’t do
→ Is that because of your health?
c. Walking across the room? USE
Yes
→ Do you get help with walking?
OF CANE OR WALKER IS
OKAY
No
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Yes
No
Yes
Yes
No
No
Yes
Yes
No
No
SAKK C-SGA_Table2_19Aug13
d. Doing light housework (like
washing dishes, straightening up,
or light cleaning?
e. Bathing or showering?
Don’t do
Yes
→
→
Is that because of your health?
Do you get help with light
housework?
Yes
Yes
No
No
No
Don’t do
Yes
→
→
Is that because of your health?
Do you get help with bathing or
showering?
Yes
Yes
No
No
No
Don’t do
→
Is that because of your health?
Yes
No
Modified Medical Outcomes Study Social Support Survey (mMOS-SS)
People sometimes look to others for companionship, assistance or other types of support. I’d like you to tell me how
often each of the following kinds of support are available to you if you need it?
If you needed it, how often is someone available…
4.
5.
6.
7.
8.
9.
10.
11.
…to help you if you were confined to bed
…to take you to the doctor if you need it
…to have a good time with
…to prepare your meals if you are unable
to do it yourself
…to help with daily chores if you were s
…to turn to for suggestions about how to
deal with a personal problem
…who understands your problems
…to love and make you feel wanted
None of
the time
A little of
the time
Some of
the time
Most of
the time
All of the
time
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
1
2
2
3
3
4
4
5
5
Geriatric Depression Scale (GDS-5)
12.
13.
14.
15.
Are you basically satisfied with your life?
Do you often get bored?
Do you often feel helpless?
Do you prefer to stay at home, rather than going out and doing new
things?
16. Do you feel pretty worthless the way you are now?
0 = Yes
0 = Yes
0 = Yes
0 = Yes
0 = Yes
1= No
1= No
1= No
1= No
1= No
Mini Nutritional Assessment (MNA)
17. Has food intake declined over the past 3 months due to loss of
appetite, digestive problems, chewing or swallowing difficulties?
0 = severe loss of appetite
1 = moderate loss of appetite
2 = no loss of appetite
18. Weight loss during the last 3 months
0 = weight loss greater than 3kg (6.6lbs)
1 = does not know
2 = weight loss between 1 & 3kg (2.2lbs
& 6.6lbs)
3 = no weight loss
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SAKK C-SGA_Table2_19Aug13
19. Has suffered psychological stress or acute disease in the past 3
months
1= Yes
0 = No
Optional Questions:
Mobility (can use VES-13 instead)
0 = bed or chair bound
1 = able to get out of bed/chair but does
not go out
2 = goes out
Neuropsychological problems (can use GDS-5 and MiniCog instead)
0 = severe dementia or depression
1 = mild dementia
2 = no psychological problems
Mini Cog
"ball” “car” “man"
20. I would like to test your memory. Can you
repeat the words I said?
21. Inside the circle draw the hours of a clock
as if a child would draw them. Place the
hands of the clock to represent the time
“forty five minutes past ten o’clock”
22. Recall: What were the three words I asked
you to say earlier?
____________ _____________ _____________
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